North Tees and Hartlepool NHS Foundation Trust

We inspected North Tees and Hartlepool Hospital NHS Foundation Trust from 7-10 July 2015 and undertook an unannounced inspection on 29 July 2015. We carried out this comprehensive inspection as part of the Care Quality Commission (CQC) comprehensive inspection programme.

The trust has a well-established executive team with the Chief Executive being in post since 1 April 2007 and the more recent appointment of the Director for Human Resources in 2014. It has been a Foundation Trust since 2007 and in 2008 became an integrated provider of acute and community services.

• The University Hospital of North Tees provides: urgent and emergency care; medical care; surgical care; critical care; maternity services; children’s and young people’s services; end of life care; outpatient services and diagnostic imaging.
• The University Hospital of Hartlepool provides: medical care; surgical care; outpatient services and diagnostic imaging
• Community services: urgent care centres; community adult and long term conditions; end of life care; community health services for children, young people and families and dental services

Overall the trust was rated as ‘Requires Improvement’ however the community services for this trust were rated as ‘Good’

Our key findings were as follows:

• Across both the acute hospital and community services, arrangements were in place to manage and monitor the prevention and control of infection. There was a dedicated infection control team to support staff and ensure policies and procedures were implemented. We found that overall, areas we visited were clean. In the Accident & Emergency Department we saw that infection control procedures were not always followed.
• Infection rates for methicillin resistant Staphylococcus aureus (MRSA) and Clostridium Difficile (C Difficile) were within an acceptable range for this size of trust
• Patients were able to access suitable nutrition and hydration, including special diets and they reported that, overall they were content with the quality and quantity of food.
• There were staffing shortages in across both nursing and medical professions with some wards unable to meet the safer staffing requirements. The trust used agency nurses and locum doctors to address the staffing requirements.
• There were processes for implementing and monitoring the use of evidence based guidelines and standards to meet the differing needs of patient groups across both the hospital and community services.
• There were a significant number of policies for medical and maternity services that we reviewed on the intranet that were out of date and required revising and updating.
• There were processes in place from ward and department level through to board level for the reporting of incidents and there was learning from incidents. Action plans from a sample of root cause analyses of serious incidents were reviewed and found to lack detailed information of actions needing to be taken.
• Equipment was well maintained both in hospital and community services.
• Governance processes were not fully developed or embedded across the divisions and there were concerns in some areas regarding the maintenance and use of risk registers. These were recognised by the trust in their revised Risk Management Strategy (2015, RM 11, V9) and plans were in place to improve the quality and effectiveness of risk registers; however these were in the early stages of implementation at the time of inspection.
• There was a clear strategic development plan called ‘Momentum’ which included both community and hospital services and focussed on integration of services and delivering care closer to home
• There were concerns regarding leadership of some services however the trust had addressed these in part at the unannounced inspection. There remained concern regarding the leadership capacity within maternity services and the impact this had on professional development and clinical standards.

We saw several areas of outstanding practice including:

• The development of advanced nurse practitioners had enabled the hospital to respond to patient needs appropriately and mitigated difficulties recruiting junior doctors.
• The bariatric service had been developed as part of a consortium arrangement with neighbouring NHS trusts to ensure the local population had access to this service.
• A training suite had been set up to simulate procedures within surgery and enabled staff to practice and upskill in a safe environment.
• The critical care team achieved a network award, which recognised excellent work in relation to “target” training. The team had also achieved recognition for their work related to critical care competencies, difficult airway and skills drills.
• The critical care team achieved 58% for its consideration of patients for tissue donation. The team were the second highest achiever for corneal donations. Overall the team’s approach to tissue and organ donation was impressive, demonstrating a compassionate and sensitive approach to patients and relatives.
• The paediatric and neonatal departments participated in a number of national and local research studies and were involved in a large number of clinical trials. The management team and several other staff told us the department had recently obtained a £3.5 million grant for an ‘OSCAR study.’ This study is for high frequency Oscillation in Acute Respiratory distress syndrome, comparing conventional positive pressure ventilation with high frequency oscillatory ventilation.
• The neonatal unit had implemented the ‘Small Wonders’ initiative for premature babies; this was designed by the charity Best Beginnings. Small Wonders supports parents in their baby’s care in ways shown to improve health outcomes for their babies.
• Staff in the maternity day assessment unit attended training on Gestation Related Optimal Weight (GROW) software which aims to reduce the number of stillbirths by using customised growth charts.
• ‘NIPE Smart’ had recently been implemented within the maternity directorate. This is an information technology screening management system which has a robust system of capturing data on newborn and infant screening examinations with the aim of reducing the number of babies diagnosed with a medical congenital condition at a late stage.
• Outpatient department staff produced posters and delivered presentations at the International Society of Orthopaedic and Trauma nurses on the development of virtual fracture clinics and on the roles of speciality nurses.
• A number of staff within the outpatients department completed modules on service improvement including one current project to improve the staff engagement and sustainability in clinical supervision.
• Staff worked on the development of health promotion packs within main outpatients to be rolled out within the orthopaedic department as a pilot to explore how this can be sustained.
• The lead consultant radiologist for the specialist procedure known as CTPA (CT pulmonary angiography) presented the experiences of staff and patient outcomes to a panel at a major CT equipment manufacturer.
• A project in conjunction with Hartlepool Council was initiated to improve health care for people living with learning disabilities. When a patient with learning disabilities was admitted to the hospital, an alert was generated and they were admitted to a virtual ward managed by the learning disabilities lead nurse. This ensured that the trust was able to respond to their needs in an appropriate and timely manner.
• One of the senior dental officers made contact with the trust’s learning disability lead nurse. They worked together to set up a pathway for people with a learning disability who were undergoing a general anaesthetic procedure. This meant that these patients were able to visit the day unit in advance and have additional planned support whilst they were having the procedure.
• We saw extremely kind, gentle and compassionate care being given to people, and the team-working between the dentists and the dental nurses was exceptional; all aimed at delivering a good outcome for the patient.
• The health visiting service provided for refugee and asylum seeking families was outstanding. This was largely driven by the specialist health visitor and her team. They demonstrated a clear passion and dedicated insight of the issues facing ethnic minority women and children seeking refuge in Stockton. The health visitor not only provided care for the children but ensured the parents were also supported to integrate into local society and minimise the risk of social exclusion.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure that:

• There are systems and processes in place to minimise the likelihood of risks by completing the 5 Steps to Safer Surgery checklist.
• Staff follow trust policies and procedures for managing medicines, including controlled drugs. Ensure that medicines are stored according to storage requirements to maintain their efficacy in maternity services.
• Risk assessments are documented along with personal care and support needs and evidence that a capacity assessment has been carried out where required.
• Pain in children and young people is assessed and managed effectively.
• The competency criteria for staff who are triaging patients are clearly documented and include recognised competency–based triage training.
• Infection control procedures are followed in relation to hand hygiene and use of personal protective equipment.
• Resuscitation and emergency equipment is checked on a daily basis in line with trust guidelines.
• Cleanliness standards are maintained.
• Effective systems are in place which enable staff to assess, monitor and mitigate risks relating to the health, safety and welfare of people who use the service.
• All policies and procedures in the In-Hospital care directorate are reviewed and brought up to date.
• Midwifery policies, guidelines and procedural documents are up to date and evidence based.
• There are always sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner.
• All annual reviews for midwives take place on a timely basis.
• Aall staff attend the relevant resuscitation training.

In addition the trust should:

• Consider strengthening the senior nurse capacity in the A&E department.
• Consider reviewing the system for documenting the follow-up of admitted head injury patients by the A&E department
• Consider a system in A&E to enable patients with allergies to be recognised quickly and easily without the presence of medical records
• Ensure that staff are following the correct procedure when dispensing medication using the Omnicell including checking the prescription at the time of dispensing.
• Consider a continuous audit of all MCA and DoLs assessments and referrals and share lessons learned.
• Consider assessing the access to the emergency resuscitation trolley on the haematology day unit.
• Consider putting engaged notices on toilet doors to protect dignity if the door is kept unlocked for staff to gain access to vulnerable patients.
• Send electronic communication to the patient’s GP on discharge from the critical care unit.
• Ensure handover meetings are held in a private and confidential area in children’s services.
• Ensure that all patient documentation remains confidential during patient visits to the outpatients department.
• Ensure that all outpatient treatment rooms are cleaned before use.
• Ensure that formal drugs audits and stock checks carried out regularly in outpatients.
• Ensure that medicines are stored appropriately to ensure their quality is maintained.
• Ensure that clinic planning, room utilisation and staffing is effectively managed and controlled for outpatient clinics including those hosted by the trust.
• Ensure that patients in the children’s outpatient department are afforded privacy when speaking with reception staff.
• Update the risk assessment related to paediatric resuscitation in the children’s outpatient department.
• Ensure that some clean and safe methods for entertaining or distracting children are provided within the diagnostic imaging department.
• Ensure that staff adhere to the coding system for recording on medication charts
• Ensure that staff fully adhere to infection control policies and close doors on side rooms where patients are being barrier nursed.
• Ensure the processes and documentation used for appraisal of non-medical staff monitors their performance and meets their personal development needs.
• Review the process for storage of post-transfusion blood bags while retained on ward areas.
• Review whether documentation for patients living with dementia are completed and comprehensive.
• Ensure that within outpatient services, action plans from audits, risk registers and meetings are maintained, regularly revisited and amended to show where actions have been completed or remain outstanding.
• Ensure that established models of regular nursing clinical supervision are implemented for all staff involved in patient care in outpatient services.
• Ensure that patients and staff are informed on a timely basis if clinics are cancelled, including those involving clinicians and staff from other trusts.
• Ensure that strategy and management plans regarding transforming the outpatients departments are communicated to all staff.
• Consider recording decision made at the evening medical ward rounds on the critical care unit.
• Consider how the critical outreach service will be maintained.
• Review the recruitment of medical staff, particularly junior doctors in the surgical unit.
• File maternity healthcare documentation according to the trust records management policy to avoid loss or misplacement of information
• Indicate benchmark data on the maternity performance dashboard to measure performance.
• Ensure that ‘fresh eyes’ checks are recorded when undertaken.
• Review the senior midwifery structure and experience resource to ensure that all the midwifery roles needed for coordination and oversight of each service are appropriately covered.
• Monitor and internally report the level of provision of 1:1 maternity care
• Hold staff handovers in maternity services in an environment that reduces the possibility of distraction and interruption.
• Have a competency based framework in place for all grades of midwives.
• Have systems in place to achieve the nationally recommended ratio of 1:15 for supervision of midwives.
• Consider safety briefings as part of daily communication with staff in maternity services.
• Include describing the reporting arrangements for Supervisors of Midwives following investigations, audits or reviews in the maternity services risk management strategy.
• Provide simulation training exercises to prevent the abduction of an infant
• Ensure that the review of the Specialist Palliative Care Team covers the educational, developmental and support needs of staff on the community inpatient unit at University Hospital of Hartlepool
• Ensure that pain control medicines are prescribed and administered at the intended interval of time.
• Evidence how the end of life care strategy and development of services is aligned at board level.
• The trust should ensure there is a consistent approach to clinical supervision across the community adult services.
• Have systems in place to enable staff to complete mandatory training within the required timescales.
• Use interpreting services appropriately to meet the needs of children, young people and families in the community.
• Complete and record lone working risk assessments in all appropriate documentation.
• Monitor the delivery of the Health Child Programme by reviewing and improving performance measures.
• Have standard operating procedures in place to support the transition of young people from community children’s services to adult services
• Consider reviewing the trust process for prescribing antibiotics in the Minor Injuries Unit to enable them to be prescribed after 10pm when only one qualified nurse is on duty.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service Good l

Overall we found that the community dental service at North Tees and Hartlepool NHS Foundation Trust provided safe and effective care. Patients were protected from abuse and avoidable harm and there were systems in place for identifying, investigating and learning from incidents, accidents and complaints. Overall we rated the service good.

At the time of the inspection, we judged that the service was safe and people were protected from abuse and physical harm.

We judged the service was effective and that people’s care, treatment and support achieved good outcomes for them. Treatments were based on the best available evidence and the service provided good health promotion.

We judged that people were involved in their care, and were treated with compassion, kindness, dignity and respect. The service was responsive to people’s needs, specifically meeting the needs of patients who were predominantly vulnerable and had complex needs. The service was well-led in that the leadership and management of the service provided a platform on which a holistic pattern of oral health care could be provided.

In coming to these judgements we spoke with patients and carers, staff who worked in the community dental clinics and the oral health promotion team. We inspected the facilities in five clinics (100% of the trusts dental locations) at Eston Clinic, Guisborough Primary Care Hospital, the One Life Centre in Hartlepool, North Ormesby Health Village and Lawson Street Health Centre. We spoke to 5 service users, 10 relatives or carers and observed 9 patients receiving dental treatments. We examined 20 clinical patient records and spoke to 14 members of staff.

Overall we rated safety as good. There were systems in place to report incidents and staff told us they knew how to report incidents and received feedback from these. Staff were able to give examples on how they had learnt from incidents and how improvements were implemented. We found there were sufficient numbers of staff to make sure that care was delivered to meet patient needs and sickness rates were below the trust target of 6%. Staff had undertaken relevant mandatory training and safeguarding training and compliance rates were above 92%.

We rated effective as good. The trust monitored and identified whether they followed appropriate NICE guidance relevant to the services they provided. The service worked in conjunction with other colleagues in the trust to develop integrated care pathways in order to facilitate the delivery of care closer to home and reduce the length of time a patient needs to remain as an inpatient. Within the therapy service patient specific outcome measures were widely used to monitor and demonstrate effective care delivery and outcomes. However, within community nursing services we found there was no formalised process for clinical supervision in place. Staff told us there were differences across the trust in how this was implemented. Some staff told us they accessed clinical supervision regularly and it worked well whereas other staff told us there was no system to access supervision.

We rated the caring domain as good. We observed care being delivered and listened to staff speaking to patients and relatives on the telephone. In order to gain an understanding of people’s experiences of care, we talked to patients and their relatives who used services. During our visit we saw that patients and relatives were treated with respect, dignity and compassion and we saw caring and compassionate care being delivered. Staff were seen to be very reassuring towards patients, their relatives and other people. People we spoke with during the inspection told us they had been involved in the planning of their care.

Overall we rated the service as good as being responsive to people’s needs. The trust had a range of specialist services to meet the different needs of people which included teams for diabetes, heart failure, continence, falls and neurophysiotherapy. The dementia strategy supported the specific needs of patients; the dementia strategy covered both inpatient hospital care and patients in the community. Analysis of data showed that since April 2014 the trust achieved the referral to treatment (RTT) targets of 95% for musculoskeletal (MSK) services and podiatry services. We saw evidence the service monitored these monthly and between April and June 2015 the services continued to achieve above the 95% target. The trust had in place a concerns and complaints policy and procedure. We saw there was complaints information available within the areas we visited. Learning from complaints was shared where improvements had been identified. The outcome of the investigation was shared with the patient and an action plan was prepared that senior staff shared with their teams.

We rated the service as requires improvement for well-led. We saw the service had a risk register which identified the risk rating and what control measures the service had put in place. However, on review of the risk registers the reasons why some of the risks had been put on the risk register were unclear. Some risks were classed as generic, such as the risk of dermatitis due to allergy and exposure to skin irritants and the risk of needle stick injury. These would usually be identified on an individual basis rather than as a service risk under the relevant health and safety policy / procedure. Following the inspection, the trust told us these had been put on the risk register in response to specific incidents in the HPV (Human Papilloma Virus) immunisation team and in the GP services where unsheathed needles had been used. 

Staff told us on the whole they felt well supported by their managers and the senior management team within the directorate. Staff also reported they felt listened to and their managers were approachable. However, some staff told us whilst they felt supported by their direct line manager they felt management teams above them did not understand the pressures within the service. We found some staff were unclear about the nursing leadership for the district nursing service at the trust. We found reporting incidents was embedded across the service and we saw evidence of staff receiving feedback and learning was shared.  We found action plans were developed following serious incidents and the actions and progress had been monitored.

Overall, we rated community health services for children, young people and families as good.

Children and young people’s services were safe. Staff knew how to manage and report incidents and we saw there had been learning following a serious case review. There were good safeguarding processes in place and staff received regular formal supervision. Staffing levels and caseloads were manageable and recruitment plans were in place to ensure health visiting vacancies were filled. In addition, the clinics and children’s centres we visited were clean.

Children and young people’s services were effective. Although some performance measures were being missed, care and treatment was evidence based and staff were competent. The trust had also successfully implemented evidence based programmes, such as the family nurse partnership programme. There were policies and procedures in place to support staff and ensure that services were delivered effectively and efficiently. There was good evidence of multidisciplinary and multi-agency working across the services.

Children and young people’s services were very caring. Staff were passionate about delivering high quality care and were very dedicated to their patients.

Children and young people’s services were responsive. Services were planned and delivered to meet the needs of the local population in line with the commissioning framework of the trust. Staff worked hard to meet the needs of children and families in vulnerable circumstances and there were support networks in place to ensure children and young people were protected.

Children and young people’s services were well-led. The majority of staff we spoke with understood the vision and strategy for their own service and also the wider trust. There were issues with some aspects of the leadership structure due to the prolonged absence of a senior member of the team. However, plans were in place to address the shortfall. We found the culture was open and transparent and there was strong evidence of collaborative team working across all services.

Overall rating for this core service Good

The Specialist Palliative Care team worked as part of a multidisciplinary team covering the acute and community based services, with specific team members dedicated to providing the community element of specialist care. Their role was to assess, support, deliver, monitor and evaluate end of life and palliative care provided by the trust. Services provided safe, co-ordinated care and we saw that staff were focused on continual learning and service development. Equipment used for patients at the end of life was easily accessible in the community and staff told us they felt they had the resources they needed to deliver quality care.

End of life care within the trust was influenced by national guidance such as the ‘Gold Standards Framework’ and we saw that good multidisciplinary working was in operation with the needs of the patient at the centre of all care activities. Patients and relatives we spoke with told us the care they received was delivered with care and compassion and that they were respected and treated with dignity. The trust was working towards a seven day specialist palliative care service and we saw that the needs of the local population were considered when reviewing the service provided. Improvements had been made to fast-track the discharge of people at the end of life and all staff were aware of and involved in, supporting patients to be cared for in their preferred place of care.

The specialist palliative care and end of life care services were well-led with both medical and nursing staff working to ensure the service meets the needs of patients. However, there was limited evidence that the end of life care strategy and service development had pro-active involvement at board level. In addition, in their support of the community inpatient service at University Hospital Hartlepool, the specialist palliative care team operated within a reactive rather than pro-active framework.